Program Operations Manual System (POMS)

DI 45010.020 Evaluation of Medical Development Reports

If medical development (obtained as a result of due process) confirms that the transplant was “successful” or “not determined” (i.e., no new transplant or course of dialysis), verify that termination action was previously and correctly taken. If this was not previously done, prepare the termination action now (see DI 45010.030). In some cases, the treating source may be reluctant to complete a current CMS-2728-U4. However, when other information in file indicates that the transplant is functioning without dialysis and in the absence of patient disagreement with this indication, accept the fact that the transplant is successful. If later information should indicate the contrary, the case must be reopened and an SSA-892-U3 prepared to revise the termination to a continuing entitlement to Medicare. (See DI 45001.076 for notification language.)

If medical development (obtained as a result of due process) confirms that a regular course of dialysis has ended in other than a transplant situation, verify that termination action was previously and correctly taken in accordance with DI 45010.015.

If medical development (received as a result of due process) indicates dialysis continues, or the beneficiary has begun a new course of dialysis, or has received a subsequent transplant, determine if prior termination or reversal to denial action was taken. If there was a reversal and the evidence is inconsistent with the reversal or if there is otherwise any doubt regarding the medical evidence, refer the case to OD per DI 45001.015E If prior termination action was taken, and the new evidence shows it was not appropriate (i.e., there was a return to dialysis or transplant within 12 months of cessation of dialysis or within 36 months of a transplant which occurred September 1977 or later), amend the award to reflect continuing Medicare entitlement. If prior termination action was taken, and new evidence shows it was proper but the beneficiary has subsequently had new onset of ESRD, obtain a new application, if not already done, and establish a new period of coverage per the guidelines in DI 45001.001.